Cholestatic Jaundice
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Population Covered By The Guidance
This pathway provides guidance on imaging patients with clinically and biochemically suspected cholestatic jaundice.
Date reviewed: April 2015
Date of next review: October 2023
Published: July 2015
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SYMBOL | RRL | EFFECTIVE DOSE RANGE |
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None | 0 |
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Minimal | < 1 millisieverts |
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Low | 1-5 mSv |
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Medium | 5-10 mSv |
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High | >10 mSv |
Images
Teaching Points
Teaching Points
- Ultrasound is the first imaging modality used in the algorithm for the investigation of cholestatic jaundice
- Further imaging depends on whether the bile ducts are dilated
- If the bile ducts are dilated and an ultrasound fails to demonstrate a cause, further imaging depends on a provisional clinical diagnosis. Investigations may include CT scan of the abdomen, CT cholangiogram, magnetic resonance cholangiopancreatography (MRCP) and endoscopic ultrasound (EUS)
- If the bile ducts are not dilated, hepatocellular causes of jaundice should be excluded prior to further imaging
- endoscopic retrograde cholangiopancreatography (ERCP) is reserved for therapeutic indications or if there remains ongoing clinical doubt with non-diagnostic imaging studies
References
References
Date of literature search: April 2015
The search methodology is available on request. Email
References are graded from Level I to V according to the Oxford Centre for Evidence-Based Medicine, Levels of Evidence. Download the document
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- Zhang ZY, Wang D, Ni JM, Yu XR, Zhang L, Wu WJ, et al. Comparison of three-dimensional negative-contrast CT cholangiopancreatography with three-dimensional MR cholangiopancreatography for the diagnosis of obstructive biliary diseases. Eur J Radiol. 2012;81(5):830-7. (Level III evidence). View the reference
- Mueller PR, Harbin WP, Ferrucci JT, Jr., Wittenberg J, vanSonnenberg E. Fine-needle transhepatic cholangiography: reflections after 450 cases. AJR Am J Roentgenol. 1981;136(1):85-90. (Level III evidence). View the reference
- Varghese JC, Farrell MA, Courtney G, Osborne H, Murray FE, Lee MJ. Role of MR cholangiopancreatography in patients with failed or inadequate ERCP. AJR Am J Roentgenol. 1999;173(6):1527-33. (Level II/III evidence). View the reference
- Fulcher AS, Turner MA, Capps GW, Zfass AM, Baker KM. Half-Fourier RARE MR cholangiopancreatography: experience in 300 subjects. Radiology. 1998;207(1):21-32. (Level II/III evidence). View the reference
- Soto JA, Yucel EK, Barish MA, Chuttani R, Ferrucci JT. MR cholangiopancreatography after unsuccessful or incomplete ERCP. Radiology. 1996;199(1):91-8. (Level II evidence). View the reference
- Ali M, Ahmed I, Akhtar W, Sattar A, Hussain M, Abbas Z. Diagnostic accuracy of magnetic resonance cholangio-pancreatography in evaluation of obstructive jaundice. J Pak Med Assoc. 2012;62(10):1053-6. (Level III evidence). View the reference
- Guibaud L, Bret PM, Reinhold C, Atri M, Barkun AN. Bile duct obstruction and choledocholithiasis: diagnosis with MR cholangiography. Radiology. 1995;197(1):109-15. (Level II/III evidence). View the reference
- Becker CD, Grossholz M, Becker M, Mentha G, de Peyer R, Terrier F. Choledocholithiasis and bile duct stenosis: diagnostic accuracy of MR cholangiopancreatography. Radiology. 1997;205(2):523-30. (Level III evidence). View the reference
- Soto JA, Barish MA, Yucel EK, Siegenberg D, Ferrucci JT, Chuttani R. Magnetic resonance cholangiography: comparison with endoscopic retrograde cholangiopancreatography. Gastroenterology. 1996;110(2):589-97. (Level II evidence). View the reference
- Palmucci S, Mauro LA, La Scola S, Incarbone S, Bonanno G, Milone P, et al. Magnetic resonance cholangiopancreatography and contrast- enhanced magnetic resonance cholangiopancreatography versus endoscopic ultrasonography in the diagnosis of extrahepatic biliary pathology. Radiol Med. 2010;115(5):732-46. (Level II evidence). View the reference
- Liang C, Mao H, Wang Q, Han D, Li Yuxia L, Yue J, et al. Diagnostic performance of magnetic resonance cholangiopancreatography in malignant obstructive jaundice. Cell Biochem Biophys. 2011;61(2):383-8. (Level III evidence). View the reference
- Bhat M, Romagnuolo J, da Silveira E, Reinhold C, Valois E, Martel M, et al. Randomised clinical trial: MRCP-first vs. ERCP-first approach in patients with suspected biliary obstruction due to bile duct stones. Aliment Pharmacol Ther. 2013;38(9):1045-53. (Level II evidence). View the reference
- Guarise A, Venturini S, Faccioli N, Pinali L, Morana G. Role of magnetic resonance in characterising extrahepatic cholangiocarcinomas. Radiol Med. 2006;111(4):526-38. (Level IV evidence). View the reference
- Katabathina VS, Dasyam AK, Dasyam N, Hosseinzadeh K. Adult bile duct strictures: role of MR imaging and MR cholangiopancreatography in characterization. Radiographics. 2014;34(3):565-86. (Review article). View the reference
- Weiss CR, Georgiades C, Hofmann LV, Schulick R, Choti M, Thuluvath P, et al. Intrabiliary MR imaging: assessment of biliary obstruction with use of an intraluminal MR receiver coil. J Vasc Interv Radiol. 2006;17(5):845-53. (Level III evidence). View the reference
- Reiner CS, Merkle EM, Bashir MR, Walle NL, Nazeer HK, Gupta RT. MRI assessment of biliary ductal obstruction: is there added value of T1-weighted gadolinium-ethoxybenzyl-diethylenetriamine pentaacetic acid-enhanced MR cholangiography? AJR Am J Roentgenol. 2013;201(1):W49-56. (Level III evidence). View the reference
- Saluja SS, Sharma R, Pal S, Sahni P, Chattopadhyay TK. Differentiation between benign and malignant hilar obstructions using laboratory and radiological investigations: a prospective study. HPB (Oxford). 2007;9(5):373-82. (Level III evidence). View the reference
- Kim JY, Lee JM, Han JK, Kim SH, Lee JY, Choi JY, et al. Contrast-enhanced MRI combined with MR cholangiopancreatography for the evaluation of patients with biliary strictures: differentiation of malignant from benign bile duct strictures. J Magn Reson Imaging. 2007;26(2):304-12. (Level III evidence). View the reference
- Rosch T, Braig C, Gain T, Feuerbach S, Siewert JR, Schusdziarra V, et al. Staging of pancreatic and ampullary carcinoma by endoscopic ultrasonography. Comparison with conventional sonography, computed tomography, and angiography. Gastroenterology. 1992;102(1):188-99. (Level III evidence). View the reference
- Tio TL, Sie LH, Kallimanis G, Luiken GJ, Kimmings AN, Huibregtse K, et al. Staging of ampullary and pancreatic carcinoma: comparison between endosonography and surgery. Gastrointest Endosc. 1996;44(6):706-13. (Level II/III evidence). View the reference
- Ang TL, Teo EK, Fock KM. Endosonography vs endoscopic retrograde cholangiopancreatography-based strategies in the evaluation of suspected common bile duct stones in patients with normal transabdominal imaging. Aliment Pharmacol Ther. 2007;26(8):1163-70. (Level III evidence). View the reference
- Tozzi di Angelo I, Prochazka V, Holinka M, Zapletalova J. Endosonography versus endoscopic retrograde cholangiopancreatography in diagnosing extrahepatic biliary obstruction. Biomed Pap Med Fac Univ Palacky Olomouc Czech Repub. 2011;155(4):339-46. (Level II evidence). View the reference
- Napoleon B. Diagnosis of biliary lesions: role of endoscopic ultrasound in the diagnosis of cholestasis. Endoscopy. 1998;30: (S1):A116-9.
- Lee YT, Chan FK, Leung WK, Chan HL, Wu JC, Yung MY, et al. Comparison of EUS and ERCP in the investigation with suspected biliary obstruction caused by choledocholithiasis: a randomized study. Gastrointest Endosc. 2008;67(4):660-8. (Level II evidence). View the reference
- Rosch T, Hofrichter K, Frimberger E, Meining A, Born P, Weigert N, et al. ERCP or EUS for tissue diagnosis of biliary strictures? A prospective comparative study. Gastrointest Endosc. 2004;60(3):390-6. (Level II/III evidence). View the reference
- Prat F, Amouyal G, Amouyal P, Pelletier G, Fritsch J, Choury AD, et al. Prospective controlled study of endoscopic ultrasonography and endoscopic retrograde cholangiography in patients with suspected common-bileduct lithiasis. Lancet. 1996;347(8994):75-9. (Level II/III evidence). View the reference
- Amouyal P, Amouyal G, Mompoint D, Gayet B, Palazzo L, Ponsot P, et al. Endosonography: Promising method for diagnosis of extrahepatic cholestasis. Lancet.334(8673):1195-8. Level II/III evidence). View the reference
- Petrov MS, Savides TJ. Systematic review of endoscopic ultrasonography versus endoscopic retrograde cholangiopancreatography for suspected choledocholithiasis. Br J Surg. 2009;96(9):967-74. (Level I evidence). View the reference
- Ross WA, Wasan SM, Evans DB, Wolff RA, Trapani LV, Staerkel GA, et al. Combined EUS with FNA and ERCP for the evaluation of patients with obstructive jaundice from presumed pancreatic malignancy. Gastrointest Endosc. 2008;68(3):461-6. (Level III evidence). View the reference
- Chu YL, Wang XF, Gao XZ, Qiao XL, Liu F, Yu SY, et al. Endoscopic ultrasonography in tandem with endoscopic retrograde cholangiopancreatography in the management of suspected distal obstructive jaundice. Eur J Gastroenterol Hepatol. 2013;25(4):455-9. (Level II evidence). View the reference
- Agarwal B, Krishna NB, Labundy JL, Safdar R, Akduman EI. EUS and / or EUS-guided FNA in patients with CT and/or magnetic resonance imaging findings of enlarged pancreatic head or dilated pancreatic duct with or without a dilated common bile duct. Gastrointest Endosc. 2008;68(2):237 -42. (Level III evidence). View the reference
- Krishna NB, LaBundy JL, Saripalli S, Safdar R, Agarwal B. Diagnostic value of EUS-FNA in patients suspected of having pancreatic cancer with a focal lesion on CT scan/MRI but without obstructive jaundice. Pancreas. 2009;38(6):625-30. (Level III evidence). View the reference
- Horwhat JD, Gerke H, Acosta RD, Pavey DA, Jowell PS. Focal or diffuse "fullness" of the pancreas on CT. Usually benign, but EUS plus/minus FNA is warranted to identify malignancy. JOP. 2009;10(1):37-42. (Level III evidence). View the reference
- Weilert F, Bhat YM, Binmoeller KF, Kane S, Jaffee IM, Shaw RE, et al. EUS-FNA is superior to ERCP-based tissue sampling in suspected malignant biliary obstruction: results of a prospective, single-blind, comparative study. Gastrointest Endosc. 2014;80(1):97-104. (Level II evidence). View the reference
- Ledro-Cano D. Suspected choledocholithiasis: endoscopic ultrasound or magnetic resonance cholangio-pancreatography? A systematic review. Eur J Gastroenterol Hepatol. 2007;19(11):1007-11. (Level I evidence). View the reference
- Alibrahim E, Gibson RN, Vincent J, Speer T, Collier N, Jardine C. Spiral computed tomography-intravenous cholangiography with three- dimensional reconstructions for imaging the biliary tree. Australas Radiol. 2006;50(2):136-42. (Level II evidence). View the reference
- Gibson RN, Vincent JM, Speer T, Collier NA, Noack K. Accuracy of computed tomographic intravenous cholangiography (CT-IVC) with iotroxate in the detection of choledocholithiasis. European Radiology. 2005;15(8):1634-42. (Level II evidence). View the reference
- Cabada Giadas T, Sarria Octavio de Toledo L, Martinez-Berganza Asensio MT, Cozcolluela Cabrejas R, Alberdi Ibanez I, Alvarez Lopez A, et al. Helical CT cholangiography in the evaluation of the biliary tract: application to the diagnosis of choledocholithiasis. Abdom Imaging. 2002;27 (1):61-70. (Level II evidence). View the reference
Further Reading
- T Hyodo, S Kumano, F Kushihata, M Okada, M Hirata, T Tsuda, et al. CT and MR cholangiography: advantages and pitfalls in perioperative evaluation of biliary tree. Br J Radiol. 2012;85(1015):887–96. (Review article). View the reference
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